Prostate Specific Antigen (PSA) is a protein produced by prostate cells which is often higher in the blood of men who have prostate cancer and is detected by performing a blood test. However, an elevated level of PSA does not necessarily mean you have cancer. PSA test is used in conjunction with Digital Rectal Examination (DRE) of the prostate to help detect prostate cancer in men and for monitoring men with prostate cancer after treatment. However, much remains unknown about how to interpret the PSA test, its ability to discriminate between cancer and benign prostate conditions, and the best course of action if the PSA is high.
Because so many questions are unanswered, the relative magnitude of the test's potential risks and benefits is unknown. When added to DRE screening, PSA enhances detection, but PSA tests are known to have relatively high false-positive rates, and they also may identify a greater number of medically insignificant tumours.
The PSA test first became available in the 1980s, and its use led to an increase in the detection of prostate cancer between 1986 and 1991. In the mid-1990s, deaths from prostate cancer began to decrease, and some observers credit PSA testing for this trend. Others, however, point out that statistical trends do not necessarily prove a cause-and-effect relationship. The benefits of prostate cancer screening are still being studied. Two large international trials are looking into prostate cancer screening. In Europe the large ERSPC trial has stopped recruiting patients. In the USA the PLCO trial has closed and men taking part are now being followed up. Early results were released in March 2009.
The PCLO study compared 2 groups of men. One group had screening every year with the PSA test and rectal examination. The other group did not have screening as part of the study. The researchers found that screening did not reduce the number of deaths from prostate cancer after 11 years of follow up. The number of deaths was small in both groups. But the results are not clear, because some men in the trial group who were not supposed to have screening had PSA tests from their own doctors.
The ERSPC study is being carried out in 7 European countries. It compared men who had screening for prostate cancer with a PSA test every 4 years to men who had no screening. The early results show that PSA tests can detect very early prostate cancer and may reduce the number of deaths from the disease. But the men in the study need to be followed up for longer to be sure. So the men in the study will carry on being followed up over the next few years to see whether screening reduces the number who die due to prostate cancer. The combined final results of the PCLO and ERSPC trials are due in 2010.
Until a definitive answer is found, doctors and patients should weigh the benefits of PSA testing against the risks of follow-up diagnostic tests and cancer treatments. The procedures used to diagnose prostate cancer may cause mild side effects, including bleeding and infection. Treatment for prostate cancer often causes erectile dysfunction and may cause urinary incontinence.
PCA 3 Score
What is PCA3?
Prostate Cancer gene 3 (PCA3) is a new Urinary derived gene test. PCA3 is highly specific to prostate cancer and this gene is upregulated by 66folds in tissue containing greater than 10% prostate cancer. This is in contrast to Prostate Specific Antigen (PSA), the blood test that is most commonly used to look for evidence of prostate cancer, which may be increased by conditions such as benign Prostatic enlargement (BPE) or inflammation of the prostate (prostatitis). The PCA3 test result is not affected by benign prostate conditions.
What does the test involve?
Prostate cells are shed into the urine following light prostatic massage or 'attentive' digital rectal examination (DRE), similar to the examination normally performed by your doctor. Following the examination, you will be asked to pass urine and the first part of the voided urine specimen is collected and sent to the PCA3 laboratory for analysis.
Should I have my PCA3 tested?
If you are concerned about the possibility of prostate cancer because of an elevated PSA or are feeling insecure about a previously performed (negative) biopsy, the PCA3 urine test can provide additional information that may help you and your doctor to decide whether a (further) biopsy is really needed. As prostate cancer can also be found in patients whose PSA is normal, the PCA3 test may help give further reassurance that you do not have a prostate cancer despite a normal PSA level.
The PCA3 is not a "screening" test that can be performed in isolation to tell you whether or not you do have cancer. It should be seen as part of the number of tests in the assessment by your urologist and the results has to be taken into consideration along with the PSA level, DRE and any previous prostate biopsy.
As the PCA3 test is still a new test, we are still discovering the different ways in which it may help us investigate men who have concerns about prostate cancer. We will be happy to discuss whether PCA 3 testing is relevant to the assessment of your prostate and organise this investigation if necessary. Further Information is available at www.pca3.org.
Trans Rectal Ultrasound and Prostate Biopsy
If there is a suspicion of prostate cancer, your doctor may recommend a test with transrectal ultrasound. In this procedure, a probe inserted in the rectum directs sound waves at the prostate. The echo patterns of the sound waves form an image of the prostate gland on a display screen. This allows accurate measurement of the size of your prostate. To determine whether an abnormal-looking area is indeed a tumour, the doctor can use the probe and the ultrasound images to guide a biopsy needle to the suspected tumour area under local anaesthetic. The needle collects a few pieces of prostate tissue for examination with a microscope. There is a small risk of infection related to this procedure, therefore you will be commenced on antibiotics the day prior to the biopsy and will be advised to complete the course of antibiotics. There is also a small risk of seeing blood in the urine, semen and in the back passage, although these are transient and often resolve within two weeks post biopsy. It is important that you drink a lot of water to flush out the small amount of blood from the prostate and guard against infection. The results of a biopsy are available within days.
What if the biopsy shows no prostate cancer?
Unfortunately, a negative biopsy does not give a guarantee that no cancer is present due to sampling error (like looking for a needle in a haystack). Your urologist will want to follow you up with a repeat PSA and perhaps PCA3 test after 6-12 months. Further prostate biopsy might be necessary.
It is important to reduce your risk of prostate cancer by making any necessary lifestyle and dietary changes
Diet and supplements to reduce the risk of Prostate Cancer
You are what you eat' (Ayurveda, 700 B.C.)
In recent years there has been an increasing realisation that what we put into our bodies has the potential to significantly affect its metabolism and the way the body reacts to environmental influences such as carcinogens, for example. Twin and migration studies have demonstrated that 20% of cases prostate cancer are genetic, which means that 80% are environmental, the strongest influence suspected being diet.
The following have been shown in medical studies to:-
Reduce the risk of prostate cancer
Increase the risk of prostate cancer
- A diet which is heavy in animal fat (red meat & dairy products)
- Obesity
Supplements
Although a balanced diet is part of healthy living, our lifestyle often makes this goal difficult to achieve. A number of plant extracts and minerals have historically been used over the centuries for specific medical conditions, some of which have now been used to make drugs (e.g. aspirin and digoxin) and have a scientific basis for their use (e.g. selenium, zinc, saw palmetto). The use of supplements and herbs is not guaranteed to cure any condition but offers an alternative and natural pathway to explore which is at very worst unlikely to do harm and at best might make a positive and significant difference to symptoms and the condition causing it. As always, do not exceed the specified dosage as this might be harmful.
How do I work out how serious my Prostate cancer is?
The underlying risk of the cancer is determined principally by:
>PSA: the higher the PSA, the more likely the cancer is outside the prostate; the faster the rate of change, the more likely serious cancer is present.
Gleason Score: this is a measure of how aggressive the cancer is. The two commonest patterns of cancer are each graded from 1 to 5. The two grades are summed and the total is known as the Gleason score. Therefore, this ranges from 2 to 10. Most cancers have a Gleason Score of 6: the most serious is 10 and the best is 2.
Cancer Stage: This refers to how far the cancer has spread and can be determined partially by prostate examination with a finger, and sometimes with transrectal ultrasound at the time of prostate biopsies, a Bone scan or Magnetic Resonance Imaging (MRI) scan. Bone scans indicate whether there is cancer in the bones. Sometimes, the lymph nodes in the pelvis are sampled laparoscopically to determine if cancer is present there.
Prostate Cancer Treatments Options
Prostate cancer treatment ranges from minimally-invasive (brachytherapy) to major surgery (radical prostatectomy.)
In some cases, "watchful waiting" (keeping the cancer under close observation for signs of progression) may be best.
The "Best" Prostate Cancer Treatment
The best prostate cancer treatment depends upon a man's age and general health, the stage of his prostate cancer and his personal decision.
Watchful Waiting
A man who has selected watchful waiting is a man who has chosen not to have immediate prostate cancer treatment. During the watchful waiting period, the physician keeps the cancer under close watch and this is why it sometimes is referred to as active surveillance.
The logic for watchful waiting is simple: prostate cancer often develops very slowly. With watchful waiting, the patient takes the time to consider possible treatment options. In some cases particularly with older men the prostate cancer patient will die of other causes rather than from prostate cancer.
Other factors that motivate men to choose watchful waiting are the intrusiveness of many available treatments, the potential side effects, and in some cases limited long-term data.
Watchful waiting entails regular PSA tests, digital rectal exams and/or other tests. "Waiting" means being alert for any indication that the cancer has developed to the point that it may require surgery or other treatment.
Choosing "Watchful Waiting"
Generally, watchful waiting is appropriate for men who meet one or more of these criteria:
Risks of Watchful Waiting
The major risk of watchful waiting is that without treatment, prostate cancer can grow and spread outside the prostate capsule before your next doctor's visit
Brachytherapy
Brachytherapy is a minimally invasive procedure where the doctor implants tiny permanent radioactive seeds (about the size of a grain of rice) into the prostate. They irradiate the cancer from inside the gland. The implanted seeds are small enough that they will not be felt by the patient. Depending on your circumstances, either radioactive Iodine (I -125) or palladium (Pd-103) will be used. Brachytherapy is also referred to as interstitial radiation therapy or seed implant therapy.
Before the seeds are implanted under anaesthesia, needles containing the seeds are then inserted through the skin of the perineum (the area between the scrotum and anus) using ultrasound guidance. The seeds remain in the prostate, where the radioactive material gives off localised radiation for a number of months to destroy the prostate cancer.
Seed implantation is an effective treatment for men with localised prostate cancer. Seed implantation requires no surgical incision and offers men a short recovery time. treatment.
External Beam Radiation Therapy (EBRT)
External beam radiation therapy (EBRT) treats prostate cancer with radiation. Before treatment starts, the doctor will order a scan or other tests to check the location and possible extension of the cancer.
During the treatment, a machine targets a beam of ionising irradiation at the target tissue. The treatment damages genetic material in all dividing cells within the target lesion. This prevents the cells from growing and they eventually die.
Patients undergoing EBRT generally receive treatment at an outpatient center five days a week for six to eight consecutive weeks.
When is EBRT Used?
EBRT is an option when the cancer is confined or slightly outside the prostate gland, it may be used alone or combined with medications or surgery.
Hormonal Therapy
All prostate cells are stimulated by the male hormone testosterone. The testicles produce 95% of a man's testosterone. The job of testosterone is to regulate the normal function, growth and development of the male reproduction organs, including the prostate gland. However when prostate cancer develops, testosterone can make the cancer grow much faster.
By either removing the testicles, or by interfering with the action of testosterone in different ways, the cancer is starved and it shrinks.
There are different ways to do this:
When is Hormone Therapy Used?
If the cancer has spread outside the prostate gland to other parts of the body, physicians normally use hormonal deprivation therapy to slow the spread or growth of the cancer.
Hormone therapy may also be used to shrink the size of the prostate gland before you receive another kind of treatment (such as radiotherapy or brachytherapy).
Men whose cancer has returned after radical prostatectomy or radiation therapy may be offered hormonal therapy
Risks and Side Effects of Hormonal Therapy
All forms of hormone therapy have roughly similar side effects but every man reacts in a different way - some get a lot of side effects, some get very few.
All types of hormonal therapy may cause side effects generally known as the "Male Hormonal Withdrawal Syndrome." This syndrome may include symptoms like:
Other Potential Problems:
Surgical castration is not reversible. In some cases it may require a stay in hospital.
LHRH agonists may tend to increase tumour growth at first and make the patient's symptoms worse. This problem is called "tumour flare."
Androgen blockade treatment may cause patients to have nausea, vomiting or tenderness and swelling of their breast tissue.
Osteoporosis
Radical Prostatectomy
Radical prostatectomy is major surgery performed under general anaesthesia that removes the entire prostate gland plus some surrounding tissue. During the procedure the pelvic lymph nodes may also be sampled for a biopsy. The goal is to remove the cancer entirely and prevent its spread to other parts of the body.
Facing any kind of urologic surgery creates a great deal of anxiety for most men. Among your concerns is: "Will my body function normally following surgery?" Traditional open urologic surgery - in which large incisions are made to access the pelvic organs - has been the standard approach when surgery is warranted. Yet common drawbacks of this procedure include significant post-surgical pain, a lengthy recovery and an unpredictable, potentially long-term impact on continence and sexual function.
Fortunately, less invasive surgical options are available to many patients facing surgery for prostate cancer. The most common of these is Laparoscopic Prostatectomy, which uses small incisions. While laparoscopy can be very effective for many routine procedures, limitations of this technology prevent its use for more complex urologic surgeries.
A new category of surgery, introduced with the development of the da Vinci® Surgical System, is being used by an increasing number of surgeons worldwide for Robotic Prostatectomy. This minimally invasive approach, utilizing the latest in surgical and robotics technologies, is ideal for delicate urologic surgery. This includes prostatectomy, in which the target site is not only tightly confined but also surrounded by nerves affecting urinary control and sexual function. Using da Vinci, your surgeon has a better tool to spare surrounding nerves, which may enhance both your recovery experience and clinical outcomes.
How do I decide what to do?
You have to trade-off the advantages over the disadvantages of each option. It depends on the relative values of each. This is best done by discussing the issues with a doctor and close family. In general, if the thought of having cancer and not doing the most possible to get rid of it dominates your thinking, then you should choose an interventional treatment. There is no caste iron evidence to indicate one treatment is better than another, but many doctors believe that radical prostatectomy offers the best chance of prolonging life. It becomes more important to maximally remove the cancer if it is high risk or there are many years of life possibly ahead. On the other hand, active monitoring may be the best option if quality of life is more important than preserving a few years of life especially if there is uncertainty over the benefit of treatment and the cancer does not seem obviously to be high risk. A second opinion is often helpful.
Several websites offer details and on-line help in making decisions including
http://www.cancerbackup.org.uk/cancertype/prostate
